Letter to the Editor
Cutaneous Leishmaniasis: An Opportunistic Infection
Leishmaniasis cutánea. Una infección oportunista
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Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Dermatología, H.C.U. Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Leishmaniasis cutánea. Una infección oportunista" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1044 "Ancho" => 950 "Tamanyo" => 155136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous leishmaniasis lesion in carpus (Oriental sore).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Leishmaniasis is a parasitic disease caused by the intracellular protozoa <span class="elsevierStyleItalic">Leishmania</span>. It is transmitted by through the bite of a mosquito: the female phlebotomus. There are 21 species of <span class="elsevierStyleItalic">Leishmania</span>. The species most widespread in Spain is <span class="elsevierStyleItalic">Leishmania infantum</span> and its major reservoir is the dog.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A number of cases of leishmaniasis have been reported in patients with different rheumatic diseases who were being treated with biological drugs.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We describe a case of cutaneous leishmaniasis in a woman with rheumatoid arthritis who was receiving an anti-tumor necrosis factor (TNF)-α and methotrexate. The patient was 54 years old and had been born in Murcia, a city in southeastern Spain. She had been diagnosed with rheumatoid arthritis 5 years earlier, and was positive for rheumatoid factor and anti-cyclic citrullinated peptide antibodies. She was being treated with subcutaneous methotrexate (25<span class="elsevierStyleHsp" style=""></span>mg each week) together with adalimumab at a dose of 40<span class="elsevierStyleHsp" style=""></span>mg every 15 days. She had no significant medical history or harmful habits. The patient was in clinical remission and it was decided to increase the interval between adalimumab doses to 21 days. Weeks later, she developed a nodular and ulcerated lesion on the palmar side of her left carpus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Biopsy led to a diagnosis of cutaneous leishmaniasis. Immunosuppressive therapy was discontinued and she underwent an analytical and imaging study, which ruled out visceral leishmaniasis. The patient was treated with amphotericin B at a dose of 3<span class="elsevierStyleHsp" style=""></span>mg/kg body weight/day for 5 days, and the lesion disappeared. Intralesional treatment was not performed and there were no secondary effects of the therapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain, according to a report of the Ministry of Health dated 2012, the autonomous communities that had reported cases of leishmaniasis during the preceding decade were: Andalusia, Aragon, Balearic Islands, Cantabria, Castile-León, Catalonia, Valencian Community, Extremadura, Community of Madrid, Region of Murcia, Chartered Community of Navarre and La Rioja. According to the registry of the Center for the Coordination of Health Warnings and Emergencies, between 2002 and 2010, 82 cases were reported in Murcia.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The disease can present in 3 clinical forms<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a>: cutaneous, mucocutaneous and visceral leishmaniasis. In the cutaneous and mucocutaneous forms, the diagnosis is reached by biopsy and visualization of <span class="elsevierStyleItalic">Leishmania</span> in the cells.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The mucocutaneous form presents with erythema, erosion and ulcers around the lips and nose; the differential diagnosis should include Wegener granulomatosis, among others. In the cutaneous form, we find lesions in areas of exposed skin, like face, arms and legs. Each lesion represents a bite. Visceral leishmaniasis can present with a febrile syndrome with constitutional symptoms and manifestations depending on the affected organs (spleen, liver, bone marrow, among others).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Tumor necrosis factor-α is a cytokine implicated in the immune response against intracellular parasites. It has been involved in granuloma formation and in containing the protozoa.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Since the introduction of anti-TNF-α agents, there have been several cases of leishmaniasis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> According to the reports, it seems that the risk is greatest during the first year of treatment, and to a greater extent with infliximab than with the subcutaneous drugs.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,6</span></a> There have also been cases with other types of immunosuppressive agents, like azathioprine, methotrexate, cyclosporine, steroid and cyclophosphamide.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In immunocompromised patients, the risk of reactivation, and thus, of active visceral leishmaniasis is increasing.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4,7</span></a> In regions in which it is endemic, in an immunocompromised patient with fever, asthenia, splenomegaly and pancytopenia, this diagnostic possibility should be considered.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In our case, the patient was receiving treatment with an immunosuppressive agent, and came from an area in which leishmaniasis is endemic. Thus, upon the first diagnostic suspicion, after the development of the skin lesion, the latter was biopsied and immunosuppressive therapy was discontinued.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Moreno Martínez MJ, Moreno Ramos MJ, Sánchez Pedreño P. Leishmaniasis cutánea. Una infección oportunista. Reumatol Clin. 2017;13:181–182.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1044 "Ancho" => 950 "Tamanyo" => 155136 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous leishmaniasis lesion in carpus (Oriental sore).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Lucientes J, Castillo JA, Gracia MJ, Peribáñez MA. Flebotomos, de la biología al control. Revista Electrónica de Veterinaria REDVET. 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Balsa" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheum Dis Clin N Am" "fecha" => "2009" "volumen" => "35" "paginaInicial" => "183" "paginaFinal" => "199" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Leishmaniasis during anti-tumor necrosis factor therapy: report of 4 cases and review of the literature (additional 28 cases)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.S. Guedes-Barbosa" 1 => "I.P. Costa" 2 => "V. Fernandes" 3 => "L.M. Mota" 4 => "I. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 12 | 9 | 21 |
| 2024 October | 65 | 38 | 103 |
| 2024 September | 92 | 15 | 107 |
| 2024 August | 66 | 36 | 102 |
| 2024 July | 53 | 24 | 77 |
| 2024 June | 74 | 41 | 115 |
| 2024 May | 85 | 45 | 130 |
| 2024 April | 83 | 22 | 105 |
| 2024 March | 59 | 35 | 94 |
| 2024 February | 44 | 19 | 63 |
| 2024 January | 47 | 23 | 70 |
| 2023 December | 36 | 27 | 63 |
| 2023 November | 48 | 22 | 70 |
| 2023 October | 53 | 26 | 79 |
| 2023 September | 87 | 39 | 126 |
| 2023 August | 45 | 22 | 67 |
| 2023 July | 34 | 23 | 57 |
| 2023 June | 45 | 18 | 63 |
| 2023 May | 43 | 23 | 66 |
| 2023 April | 30 | 14 | 44 |
| 2023 March | 68 | 24 | 92 |
| 2023 February | 66 | 25 | 91 |
| 2023 January | 56 | 24 | 80 |
| 2022 December | 55 | 27 | 82 |
| 2022 November | 61 | 27 | 88 |
| 2022 October | 59 | 44 | 103 |
| 2022 September | 74 | 31 | 105 |
| 2022 August | 66 | 41 | 107 |
| 2022 July | 53 | 35 | 88 |
| 2022 June | 60 | 30 | 90 |
| 2022 May | 55 | 34 | 89 |
| 2022 April | 60 | 50 | 110 |
| 2022 March | 114 | 54 | 168 |
| 2022 February | 80 | 36 | 116 |
| 2022 January | 113 | 37 | 150 |
| 2021 December | 36 | 35 | 71 |
| 2021 November | 43 | 42 | 85 |
| 2021 October | 65 | 57 | 122 |
| 2021 September | 55 | 45 | 100 |
| 2021 August | 58 | 35 | 93 |
| 2021 July | 56 | 20 | 76 |
| 2021 June | 35 | 25 | 60 |
| 2021 May | 66 | 40 | 106 |
| 2021 April | 125 | 128 | 253 |
| 2021 March | 95 | 33 | 128 |
| 2021 February | 56 | 18 | 74 |
| 2021 January | 42 | 18 | 60 |
| 2020 December | 54 | 22 | 76 |
| 2020 November | 60 | 27 | 87 |
| 2020 October | 61 | 9 | 70 |
| 2020 September | 62 | 21 | 83 |
| 2020 August | 39 | 20 | 59 |
| 2020 July | 39 | 23 | 62 |
| 2020 June | 34 | 16 | 50 |
| 2020 May | 57 | 14 | 71 |
| 2020 April | 45 | 16 | 61 |
| 2020 March | 13 | 7 | 20 |
| 2018 December | 1 | 0 | 1 |
| 2018 September | 0 | 1 | 1 |
| 2018 May | 6 | 4 | 10 |
| 2018 April | 29 | 8 | 37 |
| 2018 March | 77 | 5 | 82 |
| 2018 February | 25 | 9 | 34 |
| 2018 January | 13 | 5 | 18 |
| 2017 December | 28 | 12 | 40 |
| 2017 November | 19 | 9 | 28 |
| 2017 October | 20 | 9 | 29 |
| 2017 September | 16 | 8 | 24 |
| 2017 August | 13 | 9 | 22 |
| 2017 July | 25 | 10 | 35 |
| 2017 June | 57 | 37 | 94 |
| 2017 May | 59 | 28 | 87 |
| 2017 April | 2 | 2 | 4 |
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